Mail in Registration Form

Professional and Continuing Education Courses

Please print out this form, then fill out and send it to the address below with your check.  A different form will be needed for each individual registering. All requested information must be provided before enrollment can be completed. These courses are not part of the sixty+ fee waiver program. For additional information contact Ms. Penny Honeycutt , Lifelong Learning, at (417) 625-9384 or toll free (866) 727-4108.

COURSE CRN NUMBERS:_____________________________________________________________

COURSE TITLES OR NAME: ___________________________________________________________

FALL: ___________ SPRING:____________ SUMMER:____________

STUDENT NAME (PLEASE PRINT):

FIRST: ____________________________________________________

LAST:_____________________________________________________

E-MAIL ADDRESS:__________________________________________

DATE OF BIRTH:______/_______/______

SOCIAL SECURITY NO: _______-_____-_______

MAILING ADDRESS:

STREET NO.: ________________________________________

CITY:_______________________________________________

STATE: _________ ZIP CODE:______________

PHONE NO: ( ______ ) _______ - ___________

Amount Enclosed: ____________

Please make checks payable to MSSU -CE --

be sure your social security number is on your check.

Mail checks and Enrollment Form to:
Missouri Southern State University
Business Office
3950 East Newman Road
Joplin, MO 64801-1595